Key Takeaways

• Just because Medicare says it covers a service doesn’t mean you’ll receive it quickly, easily, or without added effort.

• You must understand Medicare’s rules, documentation requirements, and provider limitations to ensure access to covered benefits.

Medicare Coverage: What It Says vs. What It Does

When you hear that a service is “covered by Medicare,” it sounds straightforward. However, in reality, that phrase can be misleading. Coverage doesn’t always mean ease of access. In 2025, many beneficiaries are finding that even though a benefit is technically covered, the pathway to using it is often filled with delays, denials, and red tape.

To make the most of your coverage, it’s essential to understand where the gaps and access hurdles exist—before you need care.

Prior Authorization: A Barrier Hidden in Fine Print

One of the most common access issues involves prior authorization. This is when Medicare requires approval from your plan before you receive a certain service, test, or piece of equipment.

What Typically Requires Prior Authorization:

• Advanced imaging (MRI, CT scans)

• Durable medical equipment (wheelchairs, CPAP machines)

• Home health care

• Inpatient rehab stays

In Original Medicare, prior authorization is rare, but in many Medicare Advantage plans, it is standard practice. Even if a service is listed as “covered,” your provider may need to submit documentation and await approval—which could take days or even weeks.

Delays can be critical, especially if your treatment is time-sensitive. Always check in advance whether prior authorization is required, and what the timeline looks like.

Covered but Not Available: Provider Network Limitations

Just because a service is covered doesn’t mean you can go to any doctor or facility for it—especially if you’re enrolled in a Medicare Advantage plan. These plans have provider networks, and going outside of them may result in either higher costs or full denial of coverage.

Even with Original Medicare, some specialists may not accept Medicare at all. And in rural or underserved areas, finding a Medicare-participating provider can be challenging.

How to Avoid This Problem:

• Use the online provider directory tools for your plan

• Call your provider to confirm they accept Medicare patients in 2025

• Schedule appointments well in advance, especially with specialists

You Might Be Eligible, But Are You Qualified?

Coverage often comes with eligibility criteria you must meet before Medicare will pay. This is particularly true for services like:

• Skilled nursing facility care (requires a 3-day inpatient hospital stay under Original Medicare)

• Home health care (requires being homebound and under a doctor’s plan of care)

• Physical therapy (must be deemed medically necessary with a treatment plan)

If your situation doesn’t meet every condition, the service might be denied even though it’s listed as a benefit.

What to Watch For:

• Your doctor’s notes and diagnostic codes must match Medicare’s criteria

• Incorrect hospital classification (observation vs. inpatient) can affect SNF eligibility

• Documentation must support why a service is medically necessary

Denied Claims and the Appeal Maze

You might think if Medicare denies a service or claim, that’s the end of the road. It’s not. But the appeals process can be time-consuming and frustrating.

There are five levels of appeal, and the process starts with requesting a redetermination from your plan or Medicare contractor. Timelines for each stage vary, and gathering the right paperwork takes effort.

Tips to Navigate the Appeal Process:

• Act within the time limits (usually 120 days from the notice of denial)

• Keep a record of all medical visits, bills, and communications

• Ask your doctor to submit additional evidence or justification

If successful, appeals can result in retroactive coverage—but be prepared for delays.

Mental Health Services: Covered, But Limited

Mental health services are covered by Medicare, including therapy, psychiatric visits, and medications. However, many beneficiaries still face obstacles accessing these services in 2025.

Challenges Include:

• Few mental health providers accept Medicare

• Long wait times for appointments

• Geographic shortages in rural areas

• Limited virtual care availability under certain plans

Even with coverage, finding timely, consistent care may require persistence and flexibility.

Prescription Drug Coverage and Step Therapy

Medicare Part D covers thousands of medications, but the path to getting your specific prescription may not be easy. Many plans use step therapy, which means you must try and fail with a lower-cost alternative before the plan will cover the prescribed medication.

How This Affects You:

• Your preferred medication may be delayed or denied

• You must work with your provider to try alternative options first

• Appeals are possible but can take time

Although the new $2,000 out-of-pocket cap in 2025 offers financial relief, step therapy can still cause treatment interruptions.

Home Health: Paperwork Before Care

Home health care is another area where access is conditional. It’s covered by Medicare if you meet certain requirements—but getting started often takes effort.

Before you receive services, you need:

• A face-to-face meeting with your doctor

• A signed plan of care

• Certification that you are homebound and in need of skilled services

Any delay in paperwork can delay your care. And some home health agencies may not have capacity, especially in high-demand areas.

Transportation to Care: Not as Simple as It Sounds

Transportation is not routinely covered by Original Medicare. In 2025, some Medicare Advantage plans offer limited transportation benefits, but access still varies widely by region and provider.

Issues That Arise:

• You must often schedule rides days in advance

• Trip limits or mileage caps may apply

• Coverage may only apply to certain types of appointments (e.g., dialysis)

Always read the fine print to know what’s truly included.

Preventive Services: Fully Covered, But Underused

Medicare covers a wide range of preventive services at no cost, including annual wellness visits, cancer screenings, and vaccines. However, these benefits often go unused due to lack of awareness or difficulty in scheduling timely appointments.

Make the Most of These Services:

• Schedule your annual wellness visit every year

• Ask your provider about age-appropriate screenings

• Check if any services require pre-visit forms or referrals

What It All Means for You in 2025

Medicare offers an impressive range of covered services, but the road from “covered” to “received” is not always smooth. Accessing those benefits can require extra steps, paperwork, patience, and planning.

Don’t wait until you’re in a crisis to find out what’s required. Review your plan, know what documentation is needed, and talk to your providers ahead of time.

Get Support Before You Need It

Understanding what’s actually accessible through your Medicare coverage can help you avoid surprises, delays, and denials. The truth is, many services are covered—but getting them requires active effort on your part.

If you feel overwhelmed or uncertain, reach out to a licensed agent listed on this website. They can help clarify what your specific plan covers and how to use your benefits effectively.